Cultural diversity and the long standing disparities in the global world is one thing that eludes many healthcare providers, and has presently prompted them to take the diversity in culture as a priority when providing the healthcare services.
In my personal experience, I went through a very challenging incident in my professional endeavor as a trained healthcare provider (Nurse) when I came across a Taiwanese woman, aged 39, who has been living in Hong Kong for the last one year, but was seeking treatment in a Hong Kong Hospital for the first time. This means she had never been attended to by any professional healthcare provider from any recognized hospital in Hong Kong despite admitting that she had fell sick severally during this period. She reluctantly accepted to receive some medications, claiming that they aren’t healthy in the long run. When I asked her why she did not go to hospital for treatment, and how she got treated. She answered: “The last time I caught cold, I got so weak and lacked energy. But my parents back in Taiwan had told me never to get used going to Hospital whenever I felt some mild sickness, since these hospitals mainly provide western medicine which are full of chemicals. So as I have been taught, I made hot soup and hot pepper that would make me sweat. This is because when something like my body is cold, it means I need something like hot food with some medicinal values to not only expel the cold but to also offer some treatment.” She said that before, she had spent a great deal of time, money and effort to obtain the Chinese medicine to promote good health and prevent illness for herself and family members.
Trans- cultural nursing concept
While admitting that health is one of the most important aspects of life, and that one must be ready to preserve good health through proper care, she believed that going to mainstream hospital will warrant being given western medicine, which according to her had chemical substances that could endanger her life.
Evaluation of personal feelings Vs Professionalism
I have to admit that this was the first of such case I encountered when handling a patient at the hospital. I could not believe that one person would blatantly avoid going to hospital when sick, preferring to get “natural treatment” at home even when not sure of the kind of disease she or he is suffering from. Inwardly, I felt this was a bit of madness and backwardness to some extent. But then, did I have my feelings right professionally? In actual sense, I did not show my surprise openly to her, and that is basically why she accepted to share with me her life experiences, touching on her cultural, religious, health, social and ethnic beliefs. I noticed that taking care of patients across the borders and even the Chinese themselves was more than taking care of general patients who came over to our hospital for a healthcare service. In my practice, I knew cultural differences existed but not to an extent of one failing to seek medication when sick or ill, for a reason of not trusting the western medicine.
In order to find a common ground, I applied Berlin & Fowkes’ LEARN Model that states the process of listening, explaining, acknowledging, recommending and negotiating (Baker 1997, p.127). For I knew openly expressing my feelings would cause emotional distress, I stayed calm as she narrated her story. I listened to her keenly, even though inwardly I felt some sense of prejudice, which I did not expose since I knew its consequences. I did not refute the importance of oriental medicine but explained to her the importance of going for medical check up regularly. I elaborated to her that there was nothing wrong with using oriental medicine, since they offered good and long term preventive cures, but emphasized to her the usefulness of backing up oriental medicine with western medicine for a complete and good result. In addition, I reminded her of the importance of seeking professional advice when applying both treatment methods at the same time. In this approach, I had to emphasize on the similarities between the two medicines and after a long pleading and persuasion, she promised to take the doses as advised.
We discussed together the plan for visiting hospital and treatment that would not necessarily mean when she is sick, but a regular check up for her and her family members. For I knew she had a phobia for the western medicine due to long standing cultural beliefs, I let her organize a treatment plan that would ensure she came for the healthcare services regularly at our hospital at her convenience, with some guidance on the best way to do that.
In the past decade, trans-cultural nursing has become very imperative due to the increased migration and movement of people from one place to another worldwide (Ryan, Carlton & Ali 2000, p.301; Reid & Trompf 1990, p.19). Nurses face the challenges when providing healthcare for immigrants, refugees, and other diverse groups of the world. This is because they (nurses) get to interact with different people from diverse cultural background, who hold completely diverse views in religion, health and social issues, politics, culture and customs, etc. Leininger (1984, p.9) who founded trans-cultural nursing concept gives a definition of culture as “the learned and shared beliefs, values, and life ways of a designated or particular group which are generally transmitted inter-generationally and influence one’s thinking and action mode”.
Relevant past studies and documented experiences
This incident reminded me of a study that revealed that 90% of Taiwanese believed that western medicine had some chemical elements that may cause health complications when frequently consumed, unlike oriental medicine that are more natural (Dowd, Giger & Davidhizars 1998, p.119). The study showed that quite a number of informants believed that western medicine could prevent health problems but oriental medicine was a more holistic caring approach of taking care of the whole body (p.121). Probably in no other way can one say that there exists culture significance more than healthcare provision. This is because culture influences the entire continuum decisions made from birth, to seeking medication and self care, to care of the ill. In addition, there is increasing evidence that the behavior and pattern of practice of the healthcare provider is very essential since it produce the disparities in care (Degazon 1996, p.118)
In some studies on the people of the Taiwanese origin, one key informant in the study had this to say: “our ancestors used traditional Chinese herbal medicine for thousands of years. There is a long history with how this approach benefits the human body. You just cannot ignore this history. Perhaps the folk healers may not have formal education, but they do have a lot of experience and history as their guides. I feel this approach really helps treat my health problems” (Leininger 1995, p.424). Consider another example of a Chinese couple (Mr. and Mrs. Chan) who visited one children hospital in the United States for their two year old daughter to be treated (Degazon 1996, p. 119). The nurse got frustrated because the parents of the child did not take the body temperature of the child at home. The nurse, with no attempts to know the cultural beliefs or norms of Chinese family units; directed all the questions to Mrs. Chan, who would not even respond to the questions (p.122). The Chans were not pleased since they did not receive the child’s medication, pending the result of the throat culture. Another contributor to the displeasure emanated from the fact that the nurse’s direct address to Mrs. Chan made Mr. Chan feel like receiving no respect yet their cultural belief requires that the man should be the sole decision maker (p.124). In this regard, it is difficult for a nurse to conceptualize the idea of power relations that exist between groups. For example if a patient fails to behave in a more familiar manner in line with the nurse’s recognition, he or she may be termed as “non-compliant”, a term that is obviously biased and sometimes defiant in nature.
In this personal experience, I noticed that Taiwanese had a very strong patriarchal patri-lineal, and patri-local. It was evident the Taiwanese people place a very high value in family structure all the way to the extended family, where religion, ways of life, and self respect and respect for others reigns in terms of priority. I learnt from my patient that people of Taiwanese origin had the father as the head of the family, where the descent of the children is attributed to and all the ways of life, firmness and discipline are drawn from. In a study conducted among the Taiwanese American, it was found out that it is not logical to merge all the Chinese (Taiwan, mainland, Hong Kong and Singapore) into one cultural group (Leuning, Swiggum, Wiegert, & McCullough-Zander 2002, p.42). This is because an island state of Taiwan is very different with the mainland China in terms of social, economic, and even political environment (Dreachslin 1996, p.69). The discovery showed a wide variation in terms of cultural care and beliefs, where the analyzed data revealed five major themes namely:
- Cultural care is connected to and reflected in the development of national as well as cultural identity
- Cultural care is connected to and reflected in the value of harmony and balance among the Taiwanese daily life in terms of ethno-history, social structure, and worldview to take preventive actions against illness and maintenance of well-being,
- Culture care means one has to preserve the traditional healing ways and other health care beliefs, and if necessary supplement it with the western medicine for a better result,
- Caring is an obligation for the physical provision of family members with different gender role responsibilities, and
- Caring is expressed as unconditional emotional and physical support for loved ones (Baker 1997, pp.6-8).
According to Harwood (1981, p.79), cultural values give a sense of direction to an individual as well exposing meaning of life, giving “a direct relationship between culture and health practice.” The latter brings us to a very important aspect of trans-cultural healthcare, cultural competence by the healthcare provider.
Campinha-Bacote (1999, p.203) states that healthcare provision in the modern society goes beyond “knowing the values, beliefs, practice and customs of a particular groups of people” and that there are many faces of trans-cultural health provision than knowing the national origins and race of individuals who seek health services. Language, religious affiliation , physical size, sexual orientation, gender, age, both physical and mental disability, political orientation, occupational status, socio-economic status, and geographical location represents just a few faces of diversity (Campinha-Bacote 2002a, p.181).
In order to meet the demands of the culturally diverse groups, the healthcare provider need to engage themselves in manner that would ensure they are culturally competent. According to Cross, Bazron, Dennis & Isaacs (1989, p. IV), cultural competence is “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enables that system, agency or those professionals to work effectively in cross-cultural situations”. This means that if a healthcare provider is culturally competent; he or she should have the capacity to function professionally, effectively and competently (Stebnicki & Coeling 1999, p.1312).
Clinical scholars have studied cultural variance and come up with articulated elements of trans-cultural practice in nursing. For example, Leuning, Swiggum, Wiegert & McCullough-Zander (2002, p.324) proposed some standards of trans-cultural nursing practice, in an attempt to instill cultural competence among the nurses in the delivery of health care to diverse communities in the globe. Campinha-Bacote (1998, p.6) defines cultural competence as the “the process in which the nurse continuously strives to achieve the ability and availability to effectively work within the cultural context of a client individual, family or community”. This case made me acknowledge the process of trans-cultural competence where nurses need improvement regularly on becoming culturally competent and not being culturally competent (Leuning, Swiggum, Wiegert & McCullough-Zander 2002, p.2541). I was humbled to an extent that I saw the need to continue seeking the cultural awareness through cultural knowledge acquisition and being sensitive in my approach to cultural assessments. It is this incidence that has provoked my desire to improve my cultural skills and learn how to improve my services in the healthcare industry through Campinha-Baconte’s model of cultural competence that entails; (a) cultural desire, (b) cultural awareness (c) cultural knowledge (d) cultural skill and (e) cultural encounters (Campinha-Bacote 1999, pp.203-207). However, I still feel that there is one important area which is not addressed properly by the cultural diversity concept and trans-cultural issues fronted by scholars like Campinha-Baconte and company. It is noted that tarns-cultural diversity is in itself an ethnocentric term. This is because it focuses on just how others are different from us (healthcare providers) rather than how we are different from other people, thereby portraying a picture of how others are not the way we are hence they are inferior.
Campinha-Bacote (2002 b, p.203) defines cultural desire as a nurse motivation of wanting to know and engage in the process of becoming “culturally aware, culturally knowledgeable, culturally skillful, as well as seeking cultural encounters and stands in contrast to the feeling of having to participate in this process.” I have realized that the desire to know comes from the desire within and not out of desperation. I know that for me to continue improving, I need to have the attitude of caring, as has always been said “people don’t care how much you know, until they first know how much you care (Campinha-Bacote 1998, p.304). It would require me to have a genuine desire and attitude to guide me in my effort to be flexible with different people’s from all walks of life, adopt a continuous learning mode, which Tervalon & Murray-Garcia (1998, p.117) describes as “a life-long process” which requires cultural humility.
Awareness of culture would be important to me since I would be able to self-examine myself, and explore my own cultural background into order to analyze my perception as a professional healthcare provider, that Van (2002, p.204) describes as helping one to recognize his or her own biases, prejudice and assumptions about the differences in a person. Leininger (1984, p. 323) warns that if a health care provider is not aware of his or her cultural values, the provider may unconsciously engage in a cultural imposition, described as a tendency to impose one’s cultural beliefs and behavioral patterns upon another culture. Some important questions that one should learn to ask are: “Do my actions support stigma, isolation, and devaluation of people with disability? Am I sensitive to the cultural differences in the response to and support of this population?” (Treloar 1999, p.363).
However, it has become apparent that just because a nurse or a healthcare provider shows awareness of another person’s culture does not mean the nurse is sufficiently equipped with ideas to eradicate or eliminate the prejudice, cultural conflict, bigotry, ethnic or racial bias, etc. Why do I say this? In my personal experience, it became apparent that I had a genuine bias and prejudice, yet I was aware of the cultural variance, albeit in generalized manner. It is clear that having a genuine and a positive experience with members of other cultural backgrounds and acceptance to genuinely learn the values of different cultures in terms of contribution to our society that is increasingly getting multicultural.
To acquire Cultural knowledge I would need to continuously seek and obtain a proper foundation in education related to diverse cultural and ethnic groups as advised by Campinha-Bacote (1998, p.329). I would strive to obtain cultural knowledge about each patient’s beliefs and values on matters of health that would require me to understand their personal views on world and its medication. Stebnicki & Coeling (1999, p.78) states; “the patients’ world views will explain how they interpret their illness and how it guides their thinking, doing, and being”. For instance, Taiwanese belief the most important thing in overall wellbeing is self respect in and respect of others, connecting well with the family values, (comprised of extended family members). These values are in contrast to the western cultures which have little attachment to long chain of extended families; hence caring for a Taiwanese would require the knowledge that their family lineage would reign supreme in the healthcare decision making (p. 83).
Purnell (1998, p.151) notes another important area in the knowledge acquisition process, treatment efficacy. Response to a specific type of medication by a patient would be important as has been observed. Treatment efficacy will depend on the ethnic group. Genetic, environmental, structural, and cultural variation in different ethnic groups will determine the treatment efficacy. For instance, there is a significant difference in the therapeutic ranges of lithium for manic patients in Taiwan, and United States, with the former having a range of 0.4-0.8 mEq/L, while the latter having 0.6 – 1/2 mEq/L (p.276).
These are skills that enable one to collect relevant and reliable data about a patient as he or she presents the problem, i.e. skills that would guide one to appropriately and accurately assess culturally- based physical assessment Campinha-Bacote 1999, p.205). It is a “systematic appraisal or examination of individuals, groups, and communities as to their cultural beliefs, values and practices to determine explicit needs and intervention practices within the context of the people being served” (Leininger 1978, pp.85-86). I would strive to know how physical, biological and physiological variations of a patient determine as well as influence their ability to conduct an “accurate and appropriate physical evaluation” as Purnell (1998, p.98) puts it.
My encounter with the Taiwanese woman was accidental. It was neither planned nor expected. However, I got encouraged to encounter more of such cases in order to boost my skills. Campinha-Bacote (1998, p.431) describes cultural encounter as the process that encourages a nurse to directly engage with patients from culturally diverse backgrounds in the face-to-face approach. I will therefore increase my interactions with as many patients from different cultural backgrounds a much as possible in order to refine and also modify my personal beliefs on people from different background to avoid prejudicing and stereotyping.
Through cultural encounter, I would be able to learn and assess some critical needs of the patients such language or linguistic orientation. If such needs occur, I would need to get an accurate interpretation to facilitate an accurate communication from a trained interpreter who is conversant with both the trans-cultural nursing techniques and the medical terms used by healthcare providers.
The Model Application
I have decided to use this model in my quest to better my trans-cultural nursing skills since in the real world, every person belongs to one race, human race with similar basic needs and the difference is the perception and the approach to acquisition. However, Campinha-Baconte (2002b, p.184) advises that the even the needs of different patients from the same ethnic backgrounds may express their feeling in a completely different fashions and that “quality healthcare services” may be interpreted differently by the patients. He therefore recommends that when providing the culturally responsive services, the nurse should be in a position to probe and ask herself or himself such questions as: “have I ask myself the right question?” for this question would represent “desire, awareness, knowledge, skills and encounters” of the healthcare provider (p.196).
Even though trans-cultural nursing concept has gained popularity and seems to be the buzz word in the modern healthcare provision, it is clear to notice that such models like the LEARN Model contains some ambiguous terminologies and are short of clarity in terms of outlining key concepts. For example in the period that I and my colleagues have practiced nursing, we have literally struggled to achieve clarity in some of the concepts like cultural sensitivity, cultural competence, cultural awareness as well as cultural congruence. In essence, culture and cultural diversity is normally defined by the use of such narrow concepts of geographical location, color or religion which again portrays a notion of minority Vs majority. These discrepancies in the definitions emerge when one fall short of recognizing that each and everyone of us has a cultural heritage and that each person is bound to give a biased judgment, a patient not an exception. Again, the cultural diversity concept gets confusing more e.g. the white pan-ethnic group is normally used as a reference point to draw the differences with the rest of other ethnic groups.
In the worldwide approach to discovering the tenets in cultural care differences and similarities, as well as examining the variability that exist within the cultural groups, it’ll be appropriately discovered by the use of social structure, a people’s worldview, and the environmental factors. This theoretical conceptualization would help me pick, acknowledge, and acquire skills related to the world view, cultural inclinations and the social structure (e.g. kinship, cultural values and perception, social factors, as well as ways of life) of the said group, as represented by this Taiwanese woman.
This model guides the multifaceted approach to discover the meanings and practices of care with the patients of different ethnic originality around the globe. As Leininger (1984, p.56) points out, the folk (indigenous) care system may be quite different from professional care system, creating an underlying source of conflict between two cultures with regard to healthcare promotion.” Even though researchers admit that the generic approach may be the dominant care system, there are very limited professional care system, but should be used to acknowledge the diversity that exist among the people around the globe, for their approach to healthcare is as important as the contemporary medication.
List of References
Baker C 1997, “Cultural relativism and cultural diversity: implications for nursing Practice”, Advanced Nurse Science, 20(1), 3-11.
Campinha-Bacote J 2002 a, “Cultural competence in psychiatric nursing: Have you “ASKED” the right questions?” Journal of the American Psychiatric Association, 8(16), 183-187.
Campinha-Bacote J 2002 b, “The process of cultural competence in the delivery of healthcare services: A model of care”, Journal of Transcultural Nursing, 13(3), 181-184.
Campinha-Bacote J 1999, “A model and instrument for addressing cultural competence in health care”, Journal of Nursing Education, 38(5), 203-207.
Campinha-Bacote J 1998, The process of cultural competence in the delivery healthcare services: A culturally competentm Model of care (3rd ed.), Cincinnati, OH: Transcultural C.A.R.E. Associates.
Cross T, Bazron B, Dennis K & Isaacs M 1989, Towards a culturally competent system of care, Volume 1. Washington, DC: CASSP Technical Assistance Center.
Degazon C 1996, “Cultural diversity and community health nursing practice”, In: Stanhope M, Lancaster, J. (Eds.) Community health Nursing, St. Louis, MO: C.V. Mosby pp.117-134.
Dowd B, Giger N & Davidhizars R 1998, “Use of Giger and Davidhizar’s trans cultural assessment model by health professions”, International Nursing Review 45(4), 119-123.
Dreachslin J 1996, Diversity Leadership, Chicago, Health Administration Press.
Harwood, A. (1981), Ethnicity and medical care, Boston: Harvard University Press.
Leininger M 1984, Care: The Essence of Nursing and Health, Detroit, MI: Wayne State University Press.
Leininger M 1995, Trans-cultural Nursing: Concepts, Theories, Research, and Practice, Blacklick, OH: McGraw- Hill Book Company.
Leuning C, Swiggum P, Wiegert, H & McCullough-Zander K 2002, “Proposed standards for transcultural nursing”, Journal of Transcultural Nursing, 13(1), 40- 46.
Purnell L 1998, Transcultural health care: A culturally competent approach, Philadelphia: F.A. Davis.
Reid J & Trompf P 1990, The Health of Immigrant Australia. A Social Perspective: Sydney, Harcourt Brace Jovanovich.
Ryan M, Carlton H & Ali N 2000, “Trans-cultural nursing concepts and experiences in nursing curricula”, Journal of Trans-cultural Nursing 11(4),300-307
Stebnicki J & Coeling H 1999, “The culture of the deaf”, Journal of Transcultural Nursing, 10(4), 350-357.
Tervalon M & Murray-Garcia J 1998, “Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education”, Journal of Health Care for the Poor and Underserved, 9(2), 117-125.
Treloar L 1999, “People with disabilities – the same, but different: Implications for health care practice”, Journal of Transcultural Nursing, 10(4), 350-357.
Van M 2002, “Research on the provider contribution to race/ethnicity disparities in medical care”, Med Care, (40 Suppl 1):I140-I151.